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r <br /> " SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. , <br /> _ Telephone: .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7e r�!?� 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby :Wade to the San Joaquin Local. Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin, <br /> County Ordinance No. 1862 and the Rules and Regulations of the- San Joaquin Local Health District. <br /> JOB ADDRESSAOCATION CENSUS TRACT ' <br /> Owner's Name �. Phone <br /> Address tS-d City 7J2.Q>s � . <br /> Contractor's Name `License V2C)� Phone 4Z6G-LSC <br /> y TYPE -OF WORK (Check): NEW WELL /� DEEPEN -/7 RECONDITION f7 , DESTRUCTION f7 <br /> j PUMP INSTALLATION / ' PUMP REPAIR /� :.PUMP,REPLACEMENT I T <br /> Other /_7 <br /> .DISTANCE 'TO NEAREST: SEPTIC TANK SEWER.LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 4 <br /> Domestic/Private Drilled ,-.> Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /& n <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other ' Other Information ' ' <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump a•P <br /> PUMP REPLACEMENT: . State Work Done <br /> PUMI".REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter q Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well'construetion. Within FIFTEEN DAYS <br /> , after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting.the .well. in use.. .The above <br /> information is true to the,best of my. knowledge and belief. I WILL CALL OR A-GROUT INSPECTION <br /> 1PRIOR TO GROU "AND A FINAL SPE ION. <br /> gSIGNED TITLE <br /> (DRAW PLOTPLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ` <br /> , PHASE i DATE <br /> APPLICATION' ACCEPTED ri <br /> ADDITIONAL COMMENTS: <br /> PHASE 11. GROUT INSPECTION PHASE II FINAL INSPECTION 1 <br /> INSPECTION' BY DATE INSPECTION BY/ ' DATE <br /> P H 1426 Row_ 1_76 4Z75 2M <br />